[7주차] DBT Principles in Action: CHAPTER 8 Dialectical Dilemmas and Secondary Targets

[TOC]

• [[#BIOSOCIAL THEORY AND DIALECTICAL DILEMMAS|BIOSOCIAL THEORY AND DIALECTICAL DILEMMAS]]
• [[#THE NATURE OF THE THREE DIALECTICAL DILEMMAS IN CLINICAL CONTEXT|THE NATURE OF THE THREE DIALECTICAL DILEMMAS IN CLINICAL CONTEXT]]
  • [[#Emotional Vulnerability versus Self-Invalidation|Emotional Vulnerability versus Self-Invalidation]]
  • [[#Active Passivity versus Apparent Competence|Active Passivity versus Apparent Competence]]
  • [[#Unrelenting Crisis versus Inhibited Grieving|Unrelenting Crisis versus Inhibited Grieving]]
• [[#DERIVING DBT'S SECONDARY TARGETS FROM THE DIALECTICAL DILEMMAS|DERIVING DBT'S SECONDARY TARGETS FROM THE DIALECTICAL DILEMMAS]]
• [[#SOME SUGGESTIONS FOR WORKING WITH PATIENTS AROUND DIALECTICAL DILEMMAS|SOME SUGGESTIONS FOR WORKING WITH PATIENTS AROUND DIALECTICAL DILEMMAS]]
• [[#FROM DIALECTICAL DILEMMAS TO SECONDARY TARGETS TO TREATMENT PLANNING: A CASE EXAMPLE|FROM DIALECTICAL DILEMMAS TO SECONDARY TARGETS TO TREATMENT PLANNING: A CASE EXAMPLE]]
• [[#WHY JUST THREE DIALECTICAL DILEMMAS?|WHY JUST THREE DIALECTICAL DILEMMAS?]]

이번 챕터에서 다루는 내용
(1) the crucial theoretical relationship between DBT’s biosocial theory and the dialectical dilemmas;
(2) the nature of the three dialectical dilemmas in clinical context;
(3) how we derive the secondary targets in DBT (those behavioral patterns that cause and maintain the primary target behaviors) from the dialectical dilemmas, and how we use them;
(4) how we can identify additional dialectical dilemmas and secondary targets.

BIOSOCIAL THEORY AND DIALECTICAL DILEMMAS

Emotional Vulnerability

• Emotional sensitiity
• Emotional reactivity
• Slow return to baseline

Invalidating Environment

• (1) judge, disregard, dismiss, pathologize, or otherwise punish the individual’s valid emotional responses;
• (2) intermittently reinforce the escalation of emotional responses;
• (3) oversimplify the ease of solving emotional problems.

매개 변인으로서의 Emotional Intelligence(발달이 잘 안 됐을 때 chronic and severe emotional dysregulation)

• (1) to inhibit inappropriate behavior related to strong negative or positive affect;
• (2) to self-regulate physiological arousal associated with affect;
• (3) to refocus attention in the presence of strong affect;
• (4) to organize oneself for ongoing action in the service of an external, non-mood-dependent goal.

Rather than the objective, scientific perspective of the biosocial theory, the dialectical dilemmas represent the subjective perspective of the individual. For instance, emotional vulnerability is a scientifically defined construct, seen from the “outside-in,” when we are considering the biosocial theory; but the same term, when used to name one of the dialectical dilemmas, refers to the “inside-out” perspective of one who is suffering from uncontrollable, agonizing emotional responses. -> move from the language of theory to the language of personal experience.

Once the particular dialectical dilemmas and patterns are identified, and a language to describe them that fosters collaboration is developed, the therapist and patient can work persistently on fading out the extreme patterns and replacing them with skillful ones that are conceptually located in the middle path between the two extremes.

THE NATURE OF THE THREE DIALECTICAL DILEMMAS IN CLINICAL CONTEXT

Emotional Vulnerability versus Self-Invalidation

Effective modulation of emotions

• The emotionally vulnerable individual is therefore lost at sea in wave after wave of intensified emotions that are felt to be painfully spreading, bleeding into other painful emotional responses.
• 리네한은 이런 내담자들이 "no emotional skin"이고, 그렇기 때문에 작은 바람에도 정서적 고통을 크게 느낄 수 있다고 말함.
• 고통을 경감시키기 위한 단기적으로 효과적인 방법(이지만 장기적으로는 해로운)을 사용하게 됨.
  • suicidal attempts, self-harming actions, homicidal assaults, the use of substances, episodes of dissociation, dropping out of treatment, or engaging in extreme interpersonal behaviors
    • 이런 행동들이 DBT의 primary treatment targets이 됨.
• 타인의 모욕과 경시적 태도를 내면화하여 스스로를 폄하하게 됨. 해로운 방법이지만 이러한 전략을 통해 더 큰 고통으로부터 벗어나게 되는 면이 있음. 하지만 이것이 심해질 때 자살시도로 이어질 수 있음.
• 대부분 dialectical dilemmas의 양극단을 오감. 과소통제와 과잉통제를 오감(ex. emotional vulnerability vs. self-invalidation).
  • By flipping back and forth between these two “channels,” there is no new learning of a middle path, which might include self-awareness, self-compassion, self-validation, and/or skillful means for modulating emotions. There can be a sense of stagnation and growing despair.

Active Passivity versus Apparent Competence

Communication of distress and the effective request for help

• 수용적이지 않은 반응을 여러 번 접하게 되면 아동은 스스로의 정서를 억제하게 됨.
• Apparent competence refers to the masking of emotional distress in the context of those who could conceivably provide assistance. The individual with this syndrome does not learn to experience or express emotions accurately, and may develop considerable confusion about whether he is in need of help or not.
• 치료에서 'OK', 'I am good.' 과 같은 태도를 유지하지만, 다른 사람이 자신의 고통에 공감하지 않을 거라 기대하고, 공감하더라도 도와주지 않을 것이라 기대하기 때문에(과거 경험에서의 배움) 저렇게 겉치레로 반응하게 됨.
• 이런 상황에서 Active passivity 를 보이게 됨. 즉, 가시적인 dyscontrol behavior가 나타나며 이를 통해 도움을 받게 됨. 무의식적인 과정이지만 도움을 받게 된다는 측면에서 보면 active한 기능인 것이고, 직접적으로 도움을 요청하지 않고 극단적인 행동을 통해 그렇게 한다는 점에서 passive한 것임.
• in which case the therapist assesses it in detail and works to reduce it and replace it with more skillful means for communicating distress and asking for help.
• 여섯 가지 행동 패턴 중 가장 잘 이해되지 못한 부분이며, 때로는 acting out이라는 단어에 부정적인 뉘앙스를 담아 active passivity를 가리키기도 함.
• 절박하게 도움을 바라는 마음이 태연해 보이는 태도 이면에 있음. 고통을 표현할 효과적인 소통 방식을 찾지 못했기 때문에 이런 양가적 태도를 보이는 것임을 이해하고 공감할 수 있어야 함.
  • Understood correctly, active passivity is a perfectly sensible strategy for individuals who cannot effectively communicate distress and ask for help.

Unrelenting Crisis versus Inhibited Grieving

Processing of significant losses and traumatic events

• BPD에서는 초기 외상 경험이 정신장애를 지니지 않은 사람에 비해 평균적으로 더 많음.
• invalidating environment에서 이러한 경험을 통합하지 못할 뿐만 아니라, 없었던 일 혹은 심각하지 않은 일로 받아들이게끔 상호작용이 이루어짐.
• unrealistic thinking, faulty anticipation of consequences, and confusion으로 반응할 수 있고, 심하면 자살로 이어질 수 있음.
• dyscontrol vs. overcontrol.
• overcontrol: 외상이나 grief에 연관된 자극 및 자극에 연관된 스스로의 내적 반응을 회피, 부정적 사건에 대한 기억을 차단,
  • As a result, he loses access to memories of those events and they continue to haunt him, living in the shadows of daily life, ready to return and hijack somatic and behavioral processes in a moment’s notice.
  • Inhibited grieving can result in temporary shutdowns of emotional experiencing altogether, which then set the stage for sudden eruptions of suppressed experience resulting in unrelenting crisis or the other two biologically driven patterns of active passivity and emotional vulnerability.
• The DBT therapist tries to help the patient to develop, in the case of each of the three dilemmas, a “middle path” channel whereby she can effectively 1) modulate emotions, 2) ask for help, and 3) process loss and trauma.

DERIVING DBT'S SECONDARY TARGETS FROM THE DIALECTICAL DILEMMAS

• 자해가 수치심을 느끼는 상황에서 발생한다면 수치심이 이차 타깃이 됨.(자해 행동을 줄이는 것이 일차 타깃)
• 세 가지 변증법적 딜레마의 특성과 관련하여 여섯 가지 문제 행동 패턴이 나타날 수 있음. 각각의 패턴이 primary target behavior를 촉진하거나 유지하는 데 영향을 미칠 수 있기 때문에, 각 패턴을 resolution하는 것이 이차 타깃이 될 수 있음.
  • 예를 들어 자해의 치료에서 1. self-invalidation이 그렇고 물질 남용에서는 2. unrelenting crisis의 치료가 이차 타깃이 될 수 있음.
    • 이차 타깃은 두 가지 치료 목표를 지니게 됨. 예를 들어 self-invalidation은 1) 그것의 감소와 2) increase self-validation이라는 두 목표를 지니게 됨.
      • 같은 과정이 아니라 별개의 치료 과정이라는 것.
    • self-invalidation이 반대쪽 극성인 emotional vulnerability도 두 가지 치료 목표 즉 3) decrease emotional reactivity 4) increase its antidote, emotional modulation을 갖게 됨.
      • 여섯 개 행동 패턴 중 하나를 다루는 것은 결국 네 가지 이차 치료 목표를 갖게 된다는 말로 이해함.
  • Whereas the “first draft” of a treatment plan might include the targets of 3. reducing active passivity and 4. reducing apparent competence, the more specific plan breaks these generic targets down further.
    • With respect to the pattern of active passivity, the therapist may be working toward 5) decreasing behaviors that solve problems by eliciting rescue from others and 6) increasing active problem solving.
      • Once the secondary targets are fleshed out in sufficient details, the therapist can employ DBT strategies to accomplish them.
        • For instance, increasing active problem solving may require
          • (1) improved emotion regulation skills that help to reduce avoidance,
          • (2) better interpersonal effectiveness skills to sharpen the capacity to self-assert and to say “no,” or
          • (3) more enhanced self-management skills to strengthen executive functioning.
    • With respect to the pattern of apparent competence, the therapist may be working toward
      • 7. decreasing mood dependency of behaviors
        • patient must learn to separate his current mood from his current actions such that actions are aligned with goals rather than moods.
      • 8. increasing accurate communication of emotions.
        • exercising mindful and nonjudgmental awareness of one’s negative emotions,
        • expressing emotions accurately through verbal and nonverbal channels,
        • checking to see if the intended communication has been received,
        • and being specific in asking for help.
  • unrelenting crisis versus inhibited grieving, four more secondary targets are potentially at work.
    • With respect to unrelenting crisis, the therapist is helping to 9) decrease crisis-generating behaviors and 10) increase realistic decision making and judgment.
      • 9)-(1) The therapist needs to challenge the patient’s sense that crisis after crisis is inevitable and work on ways to structure the environment, manage emotions, and make behavioral choices that reduce the likelihood of generating a crisis. 구체적으로 어떻게?
    • With respect to inhibited grieving, he is helping to 11) decrease inhibited grieving and 12) increase emotional experiencing.
      • 11)-(1) Decreasing inhibited grieving must take place in a therapeutic relationship when trust has developed. Within such a safe context the therapist helps the patient to understand that she has suffered crucial losses and traumas, that these are real and have exerted real impacts, that the process of inhibiting such memories and experiences has negative consequences, and that, with assistance, these negative life events can be approached safely and thoughtfully without losing control.
      • 생활에서 정서를 억압하지 않고 경험할 수 있게 돕고, 치료자-내담자 신뢰가 쌓이고 내담자가 정서조절 기술(the modules of core mindfulness, emotion regulation, and distress tolerance) 습득이 된 상태에서 외상 기억 처리를 원할 때 상실과 외상에 대한 치료적 개입이 이루어짐.

SOME SUGGESTIONS FOR WORKING WITH PATIENTS AROUND DIALECTICAL DILEMMAS

1. 한쪽 극성이 시사되면 다른 쪽 극성도 지니고 있을 가능성을 고려하라.
2. 어려운 용어를 피하고 내담자와 상호협력하여 내담자 눈높이에 맞는 언어를 사용하라.
3. 행동들이 어떤 식으로 패턴을 이루어 primary target behavior로 이어지는지 내담자와 치료자가 함께 볼 수 있어야 하고, secondary target을 정함에 있어서도 상호협력이 중요함.
4. secondary target을 명확하게 설정하여 diary card에서 발생 빈도와 발생의 결과를 모니터링할 수 있다.
5. It is my experience that the more clearly I can conjure up(떠올리다) this image of my patients as functional individuals in their particularly troublesome domains of functioning, and the more I can specifically identify skill sets that will serve them toward actualizing that functional..

FROM DIALECTICAL DILEMMAS TO SECONDARY TARGETS TO TREATMENT PLANNING: A CASE EXAMPLE

WHY JUST THREE DIALECTICAL DILEMMAS?

• 경험적 근거는 없지만 DIALECTICAL DILEMMAS는 정상 발달 과정의 역기능적 결과로 이해하는 것이 유용하다.
• The child with heightened, biologically based emotional vulnerability, who undertakes this developmental task in the pervasively invalidating context, experiences two dysfunctional patterns with respect to emotion modulation,
  • one more biologically driven (emotional vulnerability) and the other more socially driven (self-invalidation).
• Similarly, when the developmental task of learning to accurately identify, tolerate, and express distress, and seek support takes place in this biosocial crucible, two dysfunctional patterns come into being rather than the functional skill set of accurately expressing emotions and asking for help.
  • Active passivity is the one more driven by the biological factor, including a measure of dyscontrol as it does, and apparent competence is the one driven more by the social factor.
• And when the important developmental task of managing and processing loss and traumas takes place in the biosocial transactional force field, the dialectical dilemma of unrelenting crisis versus inhibited grieving is the outcome,
  • the former more driven by the biological factor and the latter by the invalidating environment.
• we can think of them as three excellent and typical examples of a formula by which the miscarriage of a developmental task results in two dysfunctional patterns related to that task.